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2 Ethical Perspectives of Being ‘with Woman’
Anna M. Brown; Donna Hunt (midwife); and Emily (woman)
Introduction
This chapter considers ethical issues which impact women and maternity healthcare professionals as a result of care delivery during the childbearing continuum. Women have to make informed decisions and face a myriad of choices during their journey. Equally, care providers have an obligation to provide the best available evidence and information to enable women to make choices about the model of care that is available to them, places of birth and modes of delivery. Midwives seek to deliver care that is effective, ethical and takes into consideration their professional autonomy and responsibility (NMC 2018). New professional standards for midwifery proficiencies indicate that key domains include ‘an accountable and autonomous midwife who provides safe and effective care as colleague, scholar and leader’ though models of continuity of care and carer (NMC 2018 p. 16). These expectations have ethical implications which can influence the outcomes of a woman's birthing experience and a midwife's scope of professional practice.
It is reasonable to suggest that women's experience of childbirth is influenced by the care providers and the environment in which the birth takes place. The power dynamics between the midwife's autonomy to provide care, which is embedded in knowledge, and a woman's input to the process is crucial to birth outcomes. The place of birth impacts on the woman giving birth and on the midwife's social and spatial relationship. This includes the dynamics of control in which the birth event takes place. A woman is empowered to feel in control in a ‘home’ environment where she is familiar and comfortable; whilst a midwife has knowledge of the complex settings in a hospital environment. The midwife is therefore perceived by the woman to be in control. As such, it has been argued that hospital births do not generally accommodate the midwifery construct of a belief in the competence of a woman's body to be able to birth a baby and be an active participant in the childbearing process (Davis and Walker 2010).
Midwifery Working Practices
A document published in 2011 (Birthplace in England Collaborative Group) supports evidence that considers the impact of midwife‐led intrapartum care from the user perspective (Renfew et al. 2008; Smith et al. 2008; Cheyne et al. 2013). This report suggests that this model of care offers a better birth experience. Other evidence shows how this model of care also increases women's satisfaction and reduces medical interventions during childbirth (Thompson et al. 2016, p. 67; Ross‐Davie and Cheyne 2014; Sandall et al. 2015). Walsh and Devane (2012, p. 897) suggest that the term midwife‐led care has evolved to mean ‘autonomous care by a midwife of women designated at entering the maternity services to be healthy and at low risk of complications for pregnancy and birth’. A meta synthesis of related literature identified that a midwifery‐led approach to care increased midwifery autonomy (Walsh and Devane 2012). This results in empathetic and nurturing care; a language of compassion and sensitivity which is facilitated through the midwife–woman relationship.
Previous literature, reporting the perspectives of service users, (CQC 2013; Janssen and Wiegers 2006) recognised the need for improvement in maternity care services and highlighted problems of lack of continuity of care, courtesy and professional competence. The findings from the 2013 Care Quality Commission (CQC) survey reported on missed essential elements of care as identified by women accessing maternity care services. These included lack of support and inconsistent information to women, which disempowered them when attempting to make decisions about their care. This was compounded by lack of continuity of care and carer. Unfortunately, these concerns are still relevant, as highlighted by the more recent Better Birth's report (NHS England 2016) which implies that maternity services improvements are still to be made, thus impeding optimal care in childbirth.
The publication by NHS England (2017) to implement Better Births and promote continuity of carer set out a guide to support maternity care providers to start up pilot schemes which encourage two main models of maternity care. The first, the Team Midwifery model, indicates that each woman has an individual midwife who is responsible for coordinating care whilst working in a team of four to eight midwives, with team members backing‐up their colleagues. The second suggested model was that of Total Case Loading in which each midwife is allocated a number of women to care for and then arranges her working life around the needs of the caseload (Dunkley‐Bent 2018). However, both schemes could impact on the work–life balance of midwives and have implications for health and wellbeing, resources and cost to staff and organisations. These findings are supported by Jepsen et al.'s (2016) study which suggests that midwives need to be prepared to provide a caseload service by balancing disadvantages of their work commitment and obligation, in return for appreciation and social recognition. The outcomes are a meaningful and satisfactory result for the midwife in fulfilling a woman's expectations through a positive birth experience. However, such a commitment and obligation must surely impact on the health and wellbeing of staff.
Taylor et al.'s survey (2018) and earlier literature (Yoshida and Sandall 2013) suggested that although midwives welcomed the focus on continuity of carer, they did raise issues of concern, such as confidence and safety in working across maternity settings and practical barriers such as caring responsibilities, transport and proximity to work and health issues. However, the study participants did provide helpful suggestions in support of the care models to include adequate staffing, organisation of roles and good leadership and management, induction, support and training for staff, and finally a change in the midwifery profession culture to provide continuity of care of a high standard which is safe (Sandall 2017). The survey concludes that these models of providing maternity care may not suit all midwives and would only be successful if midwives were supported at a local level (RCM 2017) to change the ways in which they practise whilst maintaining their own wellbeing. The above issues will be explored in greater depth in the next chapter. However, changing practice and ways in which midwives work to fulfil the concept of being ‘with woman’ through the models described above can have ethical implications for midwives and an impact on the maternity services for women they care for.
Ethics and Standards
It is often challenging for midwives to make decisions which are appropriate and right for the childbearing women and the families they care for (Katz Rothman 2013). Childbirth is a social phenomenon and is created through the midwife and mother relationship and responsibilities through this social process (MacLellan 2014). Moral actions, underpinning the childbirth phenomenon, are guided by ethical principles in clinical situations to support safe and effective care based on principles of ethics (McCormick 2013).
One approach to ethics, in relation to midwifery practice, is the four principles approach, as identified by Beauchamp and Childress (2013). The principles of respect for autonomy, beneficence (do good), non‐maleficence (minimise harm) and justice (treat people fairly) map well onto the profession's code (NMC 2018). The Code (NMC 2018) specifically emphasises the preservation of safety through prioritising people, effective practice and promoting professionalism and trust. The ethical importance of safety (Chadwick 2015) for women is supported by the four ethical principles: respect for autonomy supports and respects autonomous decisions by both woman and midwife; an obligation not to cause harm through the principle of non‐maleficence;